As President Trump and Republicans in Congress re-affirm their determination to repeal the Affordable Care Act (ACA), growing voices of dissent and mounting complications threaten to prolong the debate.

“It’s a tumultuous time in health care as we approach the seventh anniversary of the ACA,” said Heather Howard, director of the state health reform assistance network, Woodrow Wilson School lecturer, and Princeton Council member.

Both sides prepared to continue the fight as legislators awaited the Congressional Budget Office (CBO) report early this week analyzing the cost and impact of the Republican bill to repeal and replace major parts of ACA (Obamacare). The CBO assessment is expected to warn that millions of Americans currently insured under the ACA could lose their coverage.

Pointing out that this issue resonates far beyond the beltway and that it is the states that implement the ACA, Ms. Howard noted, “The states have a lot at stake. The governors have a lot at stake.”

She added, “Here in New Jersey we receive more than $3 billion annually, and about 800,000 people have received healthcare insurance who didn’t have it before. We’ve cut in half the number of uninsured. Those funds have helped to shore up the state budget and helped health care providers and hospitals.”

Governors dealing with reality at the local level, she pointed out, have been a moderating influence on the healthcare debate. “Chris Christie, for example, has not been a fan of the ACA, but he has been a fan of the money saved for the state, “ she said.

Ms. Howard noted that blue state governors have stood up and said ‘don’t take it away,’ but she added that half the states that have chosen to expand Medicaid are red states, like Indiana and Ohio. Of course there have also been governors who have chosen not to expand Medicaid in their states and are eager to speed the demise of the ACA.

One possibility proposed as a replacement for Medicaid are per capita caps, according to Ms. Howard, who described them as a form of block grants to the states. She warned, however, “when program funding gets capped the federal government cuts back, fund amounts shrink and people would lose health care coverage, further eroding the safety net.”

Ms. Howard went on to note that despite the advantages of increased predictability for the federal government and some flexibility for governors, a block grant proposal would set off further controversy and disadvantages.

“I would anticipate an incredible food fight in Congress over the details. I think that proposal would get bogged down in a lot of debates over a shrinking pie. Block grants of any kind would probably result in reduced benefits for many.”

As he took a closer look at his campaign promise to quickly repeal and replace Obamacare, President Trump last month observed, “Nobody knew health care could be so complicated.” That comment sounds more and more like an understatement.

Looking forward to studying the CBO report, Ms. Howard hopes to see Congress and the president avoid any hasty decisions on the many complex issues involved. “I hope there will be time for people to analyze the fiscal impact of alternatives and also the human impact,” she said. “I hope the debate will continue.”